"Life-changing Loss."

About: Fiona Stanley Hospital King Edward Memorial Hospital / Maternity care

(as a relative),

The following was sent to Fiona Stanley Hospital by registered post. Other than a phone call stating that the letter had been received by Patient Services, no other communication has been received. The letter was also provided by registered post to government ministers for health, including shadow ministers. None have responded. The letter was delivered to the office of the Prime Minster by registered post. The Prime Minister has not responded. We have received an email from Health Consumers Council WA.

This is the story of a mother and her baby. In my opinion it is a story of a mismanaged and incompetent medical establishment and the heartbreaking death of her healthy baby.

Recently, in the early evening a pregnant woman presented herself to the emergency department of Fiona Stanley Hospital in Murdoch, Western Australia. She was 19 weeks pregnant, bleeding from the vagina and experiencing intermittent abdominal pain. She was triaged by an attending nurse and told to wait in the emergency department’s public waiting area.

The young woman was pale, bleeding and suffering from intermittent abdominal muscle cramps. The pain prevented her from sitting upright so she lay across the plastic chairs while waiting to be reviewed.

The triage nurse came to the waiting area and informed the woman that the hospital’s obstetrics team would not see her because she was less than 20 weeks pregnant. The woman was told to wait to be seen by the emergency room medical staff.

After 2 hours of pain and bleeding, the woman was led to an emergency department examination room where she repeated the history of her pregnancy and the onset of symptoms. She offered a blood-soaked sanitary pad for inspection. I believe the attending nurse did not inspect the pad. She performed some basic observations and tests. The pregnant woman was given Panadol and told to wait to be seen by a doctor.

It is our belief; the attending doctor dismissed the woman’s symptoms and stated that she would normally be sent home with advice to return the following day to be seen in the obstetrics clinic. Because the woman had been referred by her private obstetrician, she would require a review by a duty obstetrician prior to being discharged.

The woman continued to wait, bleeding, in pain and fearing for the well-being of her unborn child.

In the very early hours of the following morning, an obstetrician was on duty. This obstetrician normally works in a particular team at King Edward Memorial Hospital in Subiaco, Western Australia. This team is assigned to high-risk pregnancies.

We believe at this time a second doctor received a phone call from a duty nurse asking when the pregnant woman would be discharged.

This was the first time the second doctor had heard of the pregnant patient.

This doctor had never been informed that the woman was in hospital waiting to be reviewed.

This doctor was informed by other medical staff that the woman was 19 weeks pregnant and spotting (i.e.minute blood amounts).

The young woman had been waiting at Fiona Stanley Hospital, scared, pregnant, bleeding and in pain for over 7 hours.

The second doctor attended to the patient, finding her in pain and bleeding. Again, the pregnant woman repeated her medical history and offered her sanitary pad for inspection. The doctor inspected the pad and stated that this was not spotting as other medical staff had claimed. It was a haemorrhage, a very concerning bleed.

This doctor performed an ultrasound and identified that the woman’s cervix was failing. The doctor performed an inspection of the woman’s cervix to find it swollen and irritated. The doctor was concerned that these symptoms may result in early labour and immediately called for an ambulance to transfer the woman to King Edward Memorial Hospital. We believe this was clearly a high-risk pregnancy.

The second doctor apologised several times stating that they wished they had been alerted to the pregnant woman’s case earlier. The woman’s file had not been provided to the doctor during shift handover.

The pregnant woman was admitted to King Edward Memorial Hospital Emergency Centre,  nearly 10 hours after presenting to Fiona Stanley Hospital’s Emergency Department.

The night after the woman first presented to the Fiona Stanley Emergency Department (more than 24 hours later) the baby died as the result of an early pregnancy.

In our opinion, it is unimaginable that a woman presenting with these symptoms to a modern Australian hospital could experience such incompetence. We believe that a simple, timely risk assessment by competent medical staff at Fiona Stanley Hospital would have identified the young woman’s pregnancy as high risk and the appropriate controls actioned.

We shall forever be haunted by the loss of our child and the events leading up to our child’s death. It’s a life-changing pain that will never go away.

We shall not accept nor tolerate what we believe is medical mistreatment and incompetence. It is therefore our recommendation that, without delay, Fiona Stanley Hospital (and all hospitals) should establish, implement and maintain the policies and procedures to eliminate the risk of mishandling high-risk pregnancies. This should include but not be limited to:

Competency training for triage nurses to identify and report possible high-risk pregnancies. The requirement for all pregnancies, regardless of gestation period, where the patient is experiencing abdominal pain and/or bleeding to be immediately assessed by an obstetrician and/or immediately transferred to the care of the appropriate subject matter experts.

A review of this incident should be conducted by the top management of Fiona Stanley Hospital. There are critically important lessons to be learned including, but not limited to the lack of communication regarding patient details resulting in significant delays in assessment and treatment. The results of this review should be communicated, with a personal apology, to this woman and her family.

The family shall make available their time to collaborate with and assist Fiona Stanley Hospital with their investigation into this incident.

This letter shall be provided to interested parties in order to raise awareness and hopefully lead to industry improvements that will benefit the management of healthcare.

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Responses

Response from Paul Forden, A/Chief Executive, South Metropolitan Health Service

picture of Paul Forden

Dear capslock,

Firstly, I would like to pass on my sincere condolences on your loss; it is a life-changing pain for you and all your family. Please also allow me to convey my sadness on the basis of what you have outlined in your story, it sounds as if this was an extremely distressing time for you.

I wanted to let you know I have looked into the reasons why you did not receive a response to the letter you sent us and I was pleased to be informed that a response was posted to you on the 17th October by Fiona Stanley Hospital. Please let me know if you haven’t yet received this letter.

With regards to the care and treatment you described at Fiona Stanley Hospital, it seems there are a number of opportunities for us to improve. I note that you have said you would make yourself available to collaborate and assist with any investigation into this incident. I would therefore like to meet with you and your family to better understand what occurred during your time with us. I invite you to contact me directly on 6152 1481 so we can organise a time to sit down and discuss your experience.

You can be reassured I will look into your concerns to determine what we can do differently to make sure that we don’t see a recurrence of this situation.

I look forward to hearing from you.

Kind regards

Paul Forden

A/Chief Executive

South Metropolitan Health Service

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Update posted by capslock (a relative)

Mr. Forden, thank you for your message. I confirm receipt of the letter from FSH. We will be available to progress with a plan to meet with you late November or early December. I appreciate your contact. I shall call you in due course.

Response from Graeme Boardley, A/ Executive Director, Women and Newborn Health Service, King Edward Memorial Hospital

picture of Graeme Boardley

Dear capslock

I’m sorry for your loss. What a difficult time this must be for you.

If we’re able to offer you any further support please call the Customer Service Unit on 6458 1444.

Kind regards

Graeme Boardley

A/Executive Director

Women and Newborn Health Service

Kind Edward Memorial Hospital

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